Fess

DEPARTMENT OF ORAL AND
MAXILLOFACIAL SURGERY
FUNCTIONAL ENDOSCOPIC
SINUS SURGERY
PRESENTED BY:MUSKAN SRIVASTAV
GUIDED BY: DEPT OF OMFS
INTRODUCTION
FESS-Functional endoscopic sinus surgery is often a non invasive/
minimal invasive surgical procedure that discloses sinus air cells
and sinus Ostia by having an endoscope.
It restores the paranasal sinus function by re establishing the
physiologic pattern of ventilation and mucociliary clearance.
The term FESS was given by Kennedy in 1985.
Father of FESS is professor Mesenklinger.
FUNCTIONAL ASPECT OF FESS
1. Preserving normal structure
2. Removing only obstruction
3. Preserving mucosa
4. Restoration of function
ADVANTAGE OVER OPEN SINUS PROCEDURE
1. Safe, minimally invasive, no cuts
2. Doesn’t disturb healthy tissue
3. Performed in less time with better management
4. No visible signs that surgery has been performed
5. Quick recovery.
INDICATION
1. Chronic rhinosinusitis unresponsive to medical treatment
2. Recurrent acute sinusitis
3. Sinunasal polyposis
4. Mucocele
5. Noninvasive fungal ball
6. CSF rhinorrohoea and anterior meningoncephalocele
7. Sinonasal tumor
8. Severe exophthalmos
9. Nacrimal duct(NLD) obstruction
DIAGNOSIS
The success of FESS depends upon an accurate diagnosis of
osteomeatal complex disease, either in form of mucus or polypoid
changes in the area of hiatus semilunaris or infundibulum.
The various factors employed are:
(i)Routine sinus radiographs: They are not of much value in revealing
early paranasal is sinuses.
(ii)Nasal Endoscopy: It reveals a complete examination of nasal cavity
and the osteomeatal complex.
(iii)Computed axial tomography(CAT): It is used to confirm the disease
of osteomeatal complex and paranasal sinusitis. It is relatively
expensive and requires radiation exposure.
Strategic Approach to FESS
1. Patient under General anaesthesia
2. Local vasoconstriction of the nasal cavity
3. Septoplasty or rhinoplasty
4. Management of middle turbinate
=>The anatomical variants of the middle turbinate may cause middle
meatus obstruction like Choncha Bullosa where the head of the middle
turbinate is enlarged.
5. Uncinectomy
=>It begins with an incision of the uncinate process at its anterior
attachment. The incision is extended posteriorly and inferiorly, parallel
to the upper of Hiatus semilunaris, and towards the natural ostium of
maxillary sinus.
=>It exposes the base of infundibulum and anterior wall of Ethmoid
bulla.
6.Maxillary Antrostomy
=>Maxillary antrostomy is a surgical procedure to enlarge the
opening (ostium) of the maxillary sinus.
=>It is placed just above the inferior turbinate and not more anterior
than the anterior end of the middle turbinate.
7.Frontal Sinusotomy
=>Endoscopic frontal sinusotomy involves the use of telescopes and
cameras through the nose to reach the anterior ethmoid sinus, and
then the frontal sinus above. These areas are opened and disease is
removed.
This is a picture showing the
procedure of Uncinectomy This picture shows the procedure of
maxillary antrostomy
8.Ethmoidectomy
=>An ethmoidectomy removes infected tissue and bone in
the ethmoid sinuses that blocks natural drainage.
=>Anterior group of cells drains its secretion into infundibulum
together with maxillary and frontal sinuses.
=>Posterior group of cells drains their mucus into superior meatus.
=>Mucosa is dissected over bony surface of Ethmoid bulla.
=>Main goal of anterior ethmoidectomy is complete exposure of
anterior ethmoid cells.
9.Sphenoidotomy
=>Sphenoidotomy is a surgical procedure when the natural ostium of
sphenoid sinus is enlarged in varying degrees.
=>Optic nerve and carotid artery is located in lateral and posterior
wall.Sella tursica is situated medial and superior to the sinus and
cavernous sinus located laterally.
=>Roof of sinus is very thin and is capable of CSF leak.
PROCEDURE
After suitable vasoconstriction, using cocaine or ephedrine, middle
turbinate is identified.This is the most important landmark for the
procedure.
On the lateral wall of the nose at the level of the anterior end of the
middle turbinate lies the uncinate process.This is removed exposing
the ethmoid bulla and the opening called the hiatus semilunaris into
which the frontal and maxillary sinus drain.
Anterior ethmoid air cells are then opened, allowing better ventilation
but leaving the bone covered with mucosa.
Following this, maxillary ostium is inspected and if obstructed, opened
by means of the middle meatus antrostomy. This minimal surgery will
often be sufficient to greatly improve the function of ostiomeatal
complex and therefore provide better ventilation of the maxillary,
ethmoidal and frontal sinuses.
Once the procedure is complete and haemostasis is achieved, an
antibiotic guaze pack is placed into the nostril.This packing is removed
prior to discharge of the patient.
POST OPERATIVE COMPLICATION
Bleeding
Synechiae formation
Orbital injury
Diplopia
Orbital hematoma
Blindness
CSF leak
Direct brain injury
Nasolacrimal duct injury/epiphora
Orbital haematoma/ postoperative proptosis requires immediate removal of
the nasal packing urgent ophthalmologic consultation and emergency lateral
canthotomy.

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DEPARTMENT OF ORAL AND

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